Sept. 6, 1879.] THE BRITISH MEDICAL 7OURNAL.
361
direction of the upper axis of the pelvis, upwards and forwards towards
the proecordia." Nothing more of a practical nature relating to the
line in which force should be used can be added to these words. In
inventing my repositor, I have endeavoured to construct it in such a
form as to make it possible to carry out Gooch's instructions. The rod
which supports the cup has been doubly bent, and has a pelvic and a
perineal curve. With this instrument, the fundus of the inverted uterus
maybepressed " uppwards andforwards"in a direct linewiththe axis ofthe
uterus and the pelvic inlet. Dr. Matthews Duncan, when detailing his
case, has referred to my instrument. He says: " It has been thought
advisable by Aveling to give the stem of the repositor a perineal curve,
such as is observed in Tarnier's midwifery-forceps, and for reasons ana-
logous, if not identical. But such modification of the simple straight
repositor seems to me unnecessary." I take this opportunity of ex-
plaining that the curve in Tarnier's forceps, from which I am supposed
to have derived my idea, was invented by myself and applied to my
forceps and published ten years before Tarnier made his forceps known.
When I published the first notice of my repositor, I said the straight
repositor must have a tendency to slip past the fundus; and in the nMkt
paragraph to this, in which Dr. Matthews Duncan expresses his satis-
faction with the straight instrument, he records the occurrence of the
very accident I predicted.
AIy repositor has been used three times during the past year-twice
by myself and once by Dr. John Williams. The cases are briefly as
follows.
CASE III.-Mrs. XW. came under my care suffering from chronic in-
version of the uterus. She had been treated by several eminent gynaeco-
logists with a variety of repositors and by taxis, and had been sent to
Mr. Spencer Wells to have the uterus removed. The patient, how-
ever, thought she would have one more attempt at being cured without
mutilation, and fell into my hands. It was for this case my repositor
was made, and it was applied without causing much pain on May 7th,
1878, at 3 P.M. The cup was fitted to the fundus, and by means of
four elastic rings, two in front and two behind-all being fastened to a
belt kept up by braces-pressure was exerted in a line with the axis of
the pelvic inlet to an extent never exceeding two and a half pounds.-
May 8th, 10 A.M. The uterus was found reinverted as far as the internal
os. At 9.30 P.MA., in consequence of pain, all pressure was removed
for thirteen hours.-May gth, IO.30 A.M. The repositor was again
made active.-May ioth, 1O.35 A.M. The uterus was found completely
reinverted. (Transactions of the Obstetrical Society ofLondon, vol. xx.)
This most obstinate case, therefore, was cured in sixty-seven hours and
a half, or in fifty-four and a half hours of active treatment. The
patient had no constitutional disturbance, and spent the day after in
writing and knitting.
CASE iv.-Mrs. H., aged 26, was admitted into University College
Hospital on August 30th, I878, with chronic inversion of the uterus,
under the care of Dr. John Williams.-September 3rd. My repositor
was applied.-September 4th, IO A.M. The uterus was found partly
reinverted. At II P.M., the uterus was found completely reinverted.
An offensive discharge continued for some days; but the patient was
soon discharged cured. Reposition in this case was effected in thirty-
three hours.
CASE V (not before published).-Mrs. L., aged 26, was admitted
into the Chelsea Hospital for Women, under my care, on June 4th,
1879. She had chronic complete inversion of the uterus. Previously
to her admission, attempts at reduction by taxis had been made.-
June 5th, 4.30 P.M. I applied my repositor.-June 6th, 3.15 P.M. The
uterus was found partly reinverted.-June 7th, I A.M. The patient felt
the elastic rings " suddenly go loose", and all pain ceased. Dr. Cham-
bers, paying an early visit to the hospital, found that the cup had
passed into the uterus. At 4 P.M., the cup was tilted and easily re-
moved. I passed my finger into the uterus to the fundus. The cavity
measured three inches and three-quarters. An offensive discharge con-
tinued for some days; but the patient left the hospital for the seaside
on June 25th, three weeks from the date of her admission.
An analysis of these cases shows the following results.
Dr. Barnes's single-curved repositor was actively employed five hun-
dred and twenty-eight hours without success; and the treatment, from
the first application of the instrument to its removal, was eight hundred
and forty hours.
Dr. Duncan's straight repositor was in active use more than ninety-
one hours; and the treatment, from the first application to the time of
reinversion, was four hundred and thirty-two hours.
Dr. Aveling's double-curved repositor (takling an average of three
cases) reinverted the uterus in forty hours, and the treatment lasted
forty-four hours.
These figures show, I think, incontestably that, in treating chronic
complete inversion of the uterus, the direct method is the best; and
that the success of a repositor is in exact proportion with the directness
of its action.
INVERSIO UTERI.*
By J. WALLACE, M.D.Edin.,
Obstetric Physician to the Royal Infirmary, Liverpool; and Lecturer on Midwifery
and Diseases of Women in the School of Medicine.
THE two following cases are remarkable in this respect, that in the one
symptoms of an alarming nature showed themselves, while in the other
little or no inconvenience was experienced.
CASE I.-Mrs. A., aged 25, primipara, of good health previous to
pregnancy, married, and was taken in labour at full term. She hadt
been depressed and debilitated by news of the loss of her husband a-
sea. She had a tedious labour, and was delivered by her medical atl
tendant with forceps; ergot having been previously given on severa.
occasions. She made a slow recovery. The urine had to be extracteds
She noticed that the after-discharges were profuse; and three week
after delivery a profuse vaginal hbemorrhage set in which did not yield
to astringents. Dysuria and dribbling were constant. The bowels
were constipated. She gradually lost strength, became hysterical and
delirious, and was at length seized with epileptiform convulsions. It
was thus (October 20th, i872), twelve weeks after the confinement, I
was asked to see her in consultation.
She was lying in dorsal decubitus, drowsy, with low muttering de-
lirium; pulse I20 to 135, weak; skin hot and dry; pallor of face.
The teeth were covered with sordes; the tongue was furred, covered
with aphthous spots, which extended over the tonsils and pharynx, and
interfered with deglutition. The abdomen was flaccid, not tympanitic.
She had occasional vaginal hzemorrhage.
On examination, I found in the vagina a pyriform tumour like a
polypus. There was no uterine cavity; no uterus in the normal posi-
tion, as determined by combined bladder and rectal examination, and
by rectal and suprapubic examination, the patient being under chloro-
form.
Treatmentt.-I dilated the vagina with the hand, and applied the
taxis after the combined methods of Viardel and Noeggerath, that is,
fixing the uterus with one hand pressed against the ring of the cervix
above the pubes, and grasping it per vaginarm with the other, and
bringing pressure to bear on one cornu. After forty minutes, it was
reduced suddenly. On passing the sound, it measured two inches and
a half. She was put under full doses of opium for two days. The bad
symptoms disappeared, and she recovered.
CASE ii.-Mrs. B., aged 46, married a second time, came under my
observation for influenza and somewhat obscure abdominal symptoms,
with the supposition of pregnancy. She objected to give me any
history until after I had examined the case carefully and completely ;
the result of which was that I stated she had inversion of the uterus.
She at once confessed it was so, and she knew it, and that this was the
history. Twenty-eight years ago, when eighteen years old, she was
confined with her first and only child, after a labour of three days'
duration. She recovered so far as to be up and about in the course of
three weeks, but the after-discharge continued more or less for twelve
months. She had loss of power over the sphincter ani, dysuria, and
dribbling of urine; and also partial loss of motor power over the lower
limbs, especially after exertion. These conditions continued with
varying severity for about ten years1 after which they gradually abated
and almost entirely disappeared. Menstruation became regular and
normal, and continued so until about a year ago, when it ceased, and
never returned. I advised her to let well alone. She continues well.
REMARKS.-The curious feature in the last case is this, that we find
an intelligent lady who knew her condition resolute enough to marry a
second time. It has medico-legal aspects, probably. But so well did
she feel, that on the cessation of menstruation she imagined there was
just a possibility of her being pregnant; and, under the ruse of a feigned
illness, she attempted to get what she thought was an independent
opinion. The first case, on the other hand, presented conditions of the
most extreme danger. She was entirely unconscious, presented sym-
ptoms which indicated the grave nature of the so-called typhoid state,
and had periodic convulsions of an epileptic character, each one of
which threatened to extinguish her life. Reduction of the inversion was
followed by an immediate abatement of all these grave indications, and
she regained her health.
*
Read in the Secticn of O)stetric Medicine at the \nnual Meeting of the British
Medical Association in C rk, Augi st 1 79.